A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Teach the client techniques for performing intermittent catheterization
- B. Increase the client's fluid intake to promote frequent urination.
- C. Suggest the use of incontinence pads for comfort
- D. Administer anticholinergic medications to enhance bladder function.
Correct Answer: A
Rationale: Intermittent catheterization helps manage urinary retention and prevents complications like urinary tract infections.
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Toddler's diarrhoea is characterised by:
- A. Onset over 18 months
- B. Failure to thrive
- C. Excessive consumption of cow's milk
- D. Undigested food particles in the stool
Correct Answer: D
Rationale: The correct answer is D because undigested food particles in the stool are a hallmark of toddler's diarrhoea. The other options (a, b, c, e) are less specific.
A 2-month-old male presents with tachycardia, dyspnea, tachypnea, and a gallop rhythm with no heart murmur. He was perfectly well until 1 day prior to the episode. The physical examination reveals a heart rate of 235, a temperature of 37.8°C, and a normal blood pressure with warm, well-perfused extremities. The most likely diagnosis is
- A. sepsis
- B. supraventricular tachycardia
- C. ingestion
- D. ventricular tachycardia
Correct Answer: B
Rationale: Supraventricular tachycardia can cause rapid heart rates and heart failure in infants.
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for rental perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct Answer: C
Rationale: Monitoring blood pressure is crucial after administering an antihypertensive to ensure the client does not become hypotensive.
What are FOUR possible differential diagnoses associated with aortopathy in a child, aside from Marfan’s?
- A. Ehlers-Danlos Syndrome (vascular type IV)
- B. Bicuspid aortic valve
- C. Takayasu Arteritis
- D. Unrepaired coarctation of the aorta
Correct Answer: A
Rationale: These are potential differential diagnoses associated with aortopathy in children, aside from Marfan’s syndrome, which is a common condition linked to aortic dilation.
List THREE medical management plans for biatrial enlargement.
- A. Loop diuretics (carefully)
- B. Beta-blockers (carefully)
- C. Anticoagulation
- D. All of the above
Correct Answer: D
Rationale: These are standard treatment options aimed at managing heart function, reducing fluid buildup, and preventing complications like clot formation.